There is a lot going on in our world today. Let us keep others in our thoughts……
Otherwise, all continues to be quiet on the practice front. We all are working diligently to continue to provide quality-of-care to our patients and balance the fine line of communicating that care to 3rd party reviewers explicitly & concisely.
As 2015 comes to its wonderful, festive finale there are many (at times overwhelming) details to our practices of medicine that we must keep in mind…and no, we will not be enumerating them here. However there is one, overlapping detail that providers in the inpatient and ambulatory setting must keep in mind. It is regarding patients who may be a “direct admit” to hospitals from a physician’s office/clinic.
Even though this form of admission is decreasing in occurrence, it is not completely gone. The important part is, as usual, the documentation that must be present to support why the patient is being admitted….especially regarding the 2-Midnight Rule. It must be documented, preferably within the H&P, that if your patient is being placed as an inpatient, your clinical judgement expectation is based on the clinical indicators that hospitalization will require at least a 2- midnight stay. If this expectation is not communicated, some regulators may consider the placement as outpatient observation only…and this will have significant repercussions and financial impact on our patients.
Again, keeping in mind that we continue to survive the implementation of ICD-10 and
Happy Holidays to all!
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